Effective May 5, 2020, per AHCA Policy Transmittal 2020-31 related to COVID-19, all Prior Authorization requirements and service limits for all Behavioral Health Services, including Targeted Case Management, are waived until further notice. Please contact Carisk Behavioral Health at 1-800-294-8642 for any additional questions.
Below is Community Care Plan's list of MMA services that require prior authorization as of December 1st, 2018. Please be advised that effective September 1, 2020, a list of Healthcare Common Procedure Coding System (HCPCS) codes for medications requiring prior authorization has been added.
Please be advised that CCP no longer accepts authorization requests via fax. Providers will need to submit authorization requests via PlanLink, our provider portal, and should include all necessary clinical information.
Please note that all services rendered by out of network providers require prior authorization from Community Care Plan. For Behavioral Health and Substance Abuse services that require prior authorization, please contact Carisk Behavioral Health at 1-800-294-8642.
For cases where a participating provider in not available in our network or a non-participating provider is submitting the request, please use our Pre-Certification/Authorization Request Form, click here
ADMISSION INPATIENT and FACILITY-BASED CARE | |
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ELECTIVE MEDICAL INPATIENT ADMISSION | ELECTIVE SURGICAL INPATIENT ADMISSION |
INPATIENT REHABILITATION ADMISSION | NON-ELECTIVE (EMERGENCY) ADMISSION |
NURSING FACILITY SERVICES | SKILLED NURSING FACILITY ADMISSION |
ADMISSION OBSERVATION | |
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ADMISSION / DISCHARGE SAME DAY | HOSPITAL OBSERVATION SERVICES (for any reason) |
COSMETIC/ PLASTIC/ RECONSTRUCTIVE PROCEDURES | |
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ADJACENT TISSUE TRANSFER/ REARRANGEMENT/ REPAIR INTEGUMENTARY SYSTEM | BARIATRIC SURGERY |
BLADDER REPAIR/ RECONSTRUCTION PROCEDURES | BREAST SURGICAL PROCEDURES (excludes excisions or biopsies) |
CANTHOPLASTY | CONSTRUCT BLADDER OPENING |
DESTRUCTION OF LESIONS | EYELID, EXCISION AND REPAIR |
EYELID REPAIR PROCEDURES | FOOT and TOES RECONSTRUCTION |
GASTRIC NEUROSTIMULATOR PROCEDURES | GASTRIC PROCEDURES (including laparoscopic surgery and revision of anastomosis) |
HAND AND FINGERS RECONSTRUCTION | HEAD (SKULL, FACE, TMJ) RECONSTRUCTION |
HEART DEFECT REPAIR (STRUCTURAL) | HUMERUS AND ELBOW RECONSTRUCTION |
INTRALESIONAL INJECTIONS | KERATOPROSTHESIS |
KNEE, ARTHROPLASTY | LIP/ PALATE REPAIR |
MASTOID SURGERY | NECK AND THORAX RECONSTRUCTION |
NOSE, REPAIR | OCULAR ADNEXA, STRABISMUS SURGERY |
PALATE AND UVULA REPAIR | PELVIS and HIP RECONSTRUCTION |
PENILE REPAIR | SKIN FLAPS AND GRAFTS |
CREATE TEAR SAC DRAIN | DERMATOLOGIC PHOTOCHEMOTHERAPY AND LASER TREATMENT |
TESTICULAR PROSTHESIS INSERTION |
DENTAL CARE IN A FACILITY | |
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Medically necessary dental services are authorized by the Prepaid Dental Health Plan (PDHP). CCP will be responsible for the prior authorization of the facility and ancillary medical services in the facility. |
DIAGNOSTIC IMAGING AND LAB TESTING | |
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CT SCAN (Requirement waived for high performing PCPs) | CTA AND CALCIUM SCORING |
GENETIC TESTING (no authorization is required for standard genetic tests performed on the pregnant enrollee) | MRI (Requirement waived for high performing PCPs) |
PET SCAN | SLEEP STUDY |
TRANSVAGINAL US NON-OB |
DIALYSIS | |
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HEMODIALYSIS AND PERITONEAL |
DME FOR DURABLE MEDICAL EQUIPMENT NOT LISTED BELOW, PLEASE CONTACT COASTAL CARE SERVICES AT 1-833-204-4535 |
|
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COCHLEAR DEVICE SYSTEM | |
DIABETIC SHOES | |
PATIENT LIFTS |
ELECTIVE INVASIVE PROCEDURES | |
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ABLATE HEART DYSRHYTHM FOCUS (ELETROPHYSIOLOGICAL PROCEDURES) | ABLATE INFERIOR TURBINATE |
ABORTION PROCEDURES (elective) | ADJUST BONE FIXATION DEVICE |
ANAL PRESSURE RECORD | ANAL/ URINARY EMG |
ARTHROSCOPY ALL BODY AREAS | AV SHUNT/ ANASTOMOSIS PROCEDURES |
BRONCHOSCOPIC PROCEDURES | CAPSULE ENDOSCOPY |
CARDIAC CATHETERIZATION | CARDIOVERSION, ELECTRICAL - INTERNAL |
CARPAL TUNNEL SURGERY | CATARACT SURGERY (Medically necessary cataract surgery will be authorized by 20/20 EyeCare network. CCP will be responsible for the prior authorization of the facility and ancillary medical services) |
CHEMODENERVE ECCRINE GLANDS | CHOLECYSTECTOMY, LAPAROSCOPIC |
CIRCUMCISION (AUTH REQUIRED IF AGE > 12 weeks old) | CORONARY THERAPEUTIC SERVICES |
CYSTOMETROGRAM | CYSTOSCOPY AND TREATMENT |
DENERVATION | DISCECTOMY/ VERTEBRAL BODY RESECTION |
ELECTRICAL STIMULATION, OPERATIVE | ELECTROMYOGRAPHY and NERVE CONDUCTION VELOCITY TESTING |
ENDOCERVICAL CURETTAGE | ENDOSCOPY, SURGICAL (SINUS, ESOPHAGUS, SMALL INTESTINE, STOMA) |
EPIDURAL INJECTION FOR LYSIS | EPIDURAL INJECTION FOR PAIN |
ESOPHAGOGASTRIC FUNDOPLASTY | EXCISION CYSTIC HYGROMA, AXILLARY/ CERVICAL |
GRAFT PROCEDURES ON MUSCULOSKELTAL SYSTEM (GENERAL) | HEMORRHOIDECTOMY |
HERNIA REPAIR (open and laparoscopic) | HYPERBARIC TREATMENT (Wound care center only) |
HYSTERECTOMY (with sterilization form) | HYSTEROSCOPY |
IMPLANT AND REVISION OF NEUROELECTRODES | IMPLANT COCHLEAR DEVICE |
IMPLANT CORNEAL RING | IMPLANT CRANIAL BONE GRAFT |
IMPLANT EYE SHUNT | IMPLANT INFUSION PUMP |
INSERTION OF TUNNELED INTRAPERITONEAL CATHETER | LAMINOTOMY/ LAMINECTOMY |
LAPAROSCOPY OF ABDOMEN, PERITONEUM, OMENTUM | MOHS SURGERY |
MYOMECTOMY | NEPHRECTOMY |
OPTIC NERVE, DECOMPRESSION | ORAL SURGERY |
ORCHIECTOMY, ORCHIOPEXY | OVIDUCT/ OVARY, LAPAROSCOPY |
PROCTOPEXY, LAPAROSCOPIC | PENILE IMPLANT (REMOVAL ONLY) |
PROSTATE PROCEDURES | PTERYGIUM SURGERY |
SHOULDER SURGERY/ REPAIR/ REVISION/ RECONSTRUCTION | SKIN GRAFTING PROCEDURES |
SPIDER VEIN AND ENDOVENOUS THERAPY | SPINAL IMPLANT/ PUMP/ ANALYZE |
SPINE FUSION | STERILIZATION PROCEDURES (with sterilization form) |
STRESS TEST (THALLIUM, CARDIOLYTE ETC.) | THORACOSCOPY, DIAGNOSTIC OR SURGICAL |
TOTAL DISC ARTHROPLASTY (artificial disc) | TRANSCATH STENT TO CAROTID ARTERY/ INCLUDING ANGIOPLASTY |
TRANSCATH PERM OCCLUSION/ EMBOLIZATION PERC, OF CNS | TRANSESOPHAGEAL ECHOCARDIOGRAPHY |
TYMPANOSTOMY | UTERINE FIBROID EMBOLIZATION |
HOME HEALTH FOR HOME HEALTH SERVICES, PLEASE CONTACT COASTAL CARE SERVICES AT 1-833-204-4535 |
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HOSPICE | |
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HOSPICE INPATIENT | HOSPICE OUTPATIENT AT HOME/ ALF/ SNF |
MATERNITY (Requirement Waived for High Performing OB Providers) | |
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DELIVERY (SCHEDULED CESAREAN AND INDUCTIONS) | OBSTETRICAL CARE — PRE-NATAL PROCEDURES (Prenatal sonograms do not require prior auth) |
NUTRITION SERVICES | |
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NUTRITIONAL COUNSELING | NUTRITIONAL SUPPLEMENTS/ NUTRITIONAL FORMULAS/ ENTERAL NUTRITION |
ORTHOTICS AND PROSTHETICS | |
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CRANIAL ORTHOSIS | LIMB AND TORSO PROSTHETICS |
ORTHOTICS/ PROSTHETICS | PROSTHETIC CUSTOM EYE, SURFACING & FITTING |
REHABILITATION THERAPIES (PT/OT/ST). PLEASE CONTACT HEALTH NETWORK ONE AT 1-888-550-8800 |
|
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THERAPY | |
RESPIRATORY THERAPY |
INTEGRATIVE MEDICINE SERVICES | |
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ACUPUNCTURE (Expanded Benefit—limitations apply) | |
CARDIAC REHAB | |
CHIROPRACTIC SERVICES (Prior authorization required for Expanded Benefit Only — Limitations apply) | |
EQUINE THERAPY | |
MASSAGE THERAPY (Expanded Benefit—limitations apply) |
TRANSPLANT | |
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ALL TRANSPLANT SERVICES, INCLUDING EVALUATIONS |
TRANSPORTATION | |
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AIR AMBULANCE |
MMA Pharmacy Prior Authorization List
PHYSICIAN INJECTED MEDICATIONS |
||
Procedure code |
Brand name |
|
J9035 |
BEVACIZUMAB 10MG |
AVASTIN |
J0129 |
ABATACEPT 10MG |
ORENCIA |
J0476 |
BACLOFEN 50MCG FOR INTRATHECAL TRIAL |
LIORESAL, GABLOFEN |
J0475 |
BACLOFEN PER 10MG |
LIORESAL, GABLOFEN |
J0490 |
BELIMUMAB 10MG |
BENLYSTA |
J0585 |
ONABOTULINUMTOXINA A 1 UNIT |
BOTOX |
J0717 |
CERTOLIZUMAB PEGOL 1MG |
CIMZIA |
J0881 |
DARBEPOETIN ALFA 1MCG, FOR NON-ESRD USE |
ARANESP |
J0882 |
DARBEPOETIN ALFA 1MCG |
ARANESP |
J0885 |
EPOETIN ALFA 1,000 UNITS, FOR NON-ESRD USE |
PROCRIT |
J0897 |
DENOSUMAB 1MG |
PROLIA, XGEVA |
J1442 |
FILGRASTIM G-CSF 1MCG |
NEUPOGEN |
J1447 |
TBO FILGRASTIM 1MCG |
NEUPOGEN |
J1602 |
GOLIMUMAB FOR IV USE 1MG |
SIMPONI |
J1650 |
ENOXAPARIN SODIUM 10MG |
LOVENOX |
J1652 |
FONDAPARINUX SODIUM 0.5MG |
ARIXTRA |
J3262 |
TOCILIZUMAB 1MG |
ACTEMRA |
J3358 |
USTEKINUMAB 1MG (INTRAVENOUS ONLY) |
|
J3357 |
USTEKINUMAB 1MG (SUBCUTANEOUS ONLY) |
|
J3380 |
VEDOLIZUMAB 1MG |
ENTYVIO |
J1745 |
INFLIXIMAB 10MG |
REMICADE |
J1950 |
LEUPROLIDE ACETATE PER 3.75MG (FOR DEPOT SUSPENSION) |
LUPRON |
J2357 |
OMALIZUMAB 5MG |
XOLAIR |
J2469 |
PALONOSETRON 25MCG |
ALOXI |
J2503 |
PEGAPTANIB SODIUM 0.3MG |
MACUGEN |
J2505 |
PEGFILGRASTIM 6MG |
NEULASTA |
J2778 |
RANIBIZUMAB 0.1MG |
LUCENTIS |
Q5107 |
EVACIZUMAB-AWWB BIOSIMILAR 10MG |
ZIRABEV |
Q5105 |
EPOETIN ALFA, BIOSIMILAR 100 UNITS |
RETACRIT |
Q5106 |
EPOETIN ALFA, BIOSIMILAR 100 UNITS |
RETACRIT |
Q5101 |
FILGRASTIM-SNDZ; BIOSIMILAR 1MCG |
ZARXIO |
Q5103 |
INFLIXIMAB-DYYB 10MG |
INFLECTRA |
Q5104 |
INFLIXIMAB-ABDA 10MG |
RENFLEXIS |
Q5108 |
PEGFILGRASTIM-JMDB BIOSIMILAR 0.5MG |
FULPHILA |
Q5110 |
FILGRASTIM-AAFI BIOSIMILAR 1MCG |
NIVESTYM |
Q5111 |
PEGFILGRASTIM-CBQV BIOSIMILAR 0.5MG |
UDENYCA |
J2503 |
PEGAPTANIB SODIUM 0.3MG |
MACUGEN |
J3358 |
USTEKINUMAB 1MG (INTRAVENOUS ONLY) |
STELARA |
J1453 |
FOSAPREPITANT 1MG |
EMEND |
J7324 |
HYALURONAN OR DERIVATIVE |
ORTHOVISC |
J3489 |
ZOLEDRONIC ACID 1MG |
RECLAST OR ZOMETA |
J9354 |
INJECTION, ADO-TRASTUZUMAB EMT 1 MG |
KADCYCLA |
J0378 |
RSV MAB IM 50 MG |
SYNAGIS |
J0135 |
INJECTION, ADALIMUMAB, 20 MG |
HUMIRA |
J0586 |
ABOBOTULINUMTOXIN A |
DYSPORT |
J0587 |
INJECTION, RIMABOTULINUMTOXIN B |
MYOBLOC |
J0588 |
INCOBOTULINUMTOXIN A |
XEOMIN |